Improving intensive care: observations based on organizational case studies in nine intensive care units: a prospective, multicenter study

Abstract

Objective: To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance.

Design: Prospective multicenter study. Onsite organizational analysis; prospective inception cohort.

Setting: Nine ICUs (one medical, two surgical, six medical-surgical) at five teaching and four nonteaching hospitals.

Participants: A sample of 3,672 ICU admissions; 316 nurses and 202 physicians.

Materials and methods: Interviews and direct observations by a team of clinical and organizational researchers. Demographic, physiologic, and outcome data for an average of 408 admissions per ICU; and questionnaires on ICU structure and organization. The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness; the ratio of actual/predicted length of ICU stay was used to assess efficiency.

Measurements and main results: ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational questionnaires or by global judgment following on-site analysis. Superior organizational practices among these ICUs were related to a patient-centered culture, strong medical and nursing leadership, effective communication and coordination, and open, collaborative approaches to solving problems and managing conflict.

Conclusions: The best and worst organizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management.